Question Can MA's lock their own notes

maresh411

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As far as nurse only visits that are just for flu shot or depo shot etc., and the patient doesn't see the provider at all. Can the medical assistant then lock/sign off on those notes? Or does it have to be the provider?
 

thomas7331

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For coding/billing purposes, the note just needs to be signed by the individual who performed the services. However, some organizations may require the supervising physician to co-sign the note and/or to document that the services were appropriately supervised, and your state may also have some legal requirements, so I'd recommend you get guidance from your manager as to what their expectations are for the documentation.
 

maresh411

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For coding/billing purposes, the note just needs to be signed by the individual who performed the services. However, some organizations may require the supervising physician to co-sign the note and/or to document that the services were appropriately supervised, and your state may also have some legal requirements, so I'd recommend you get guidance from your manager as to what their expectations are for the documentation.
Thank you for the response. Our Manager knows nothing about Billing/Coding. But would not care if medical assistants signed off on their notes, but we wanted to be sure it was okay for them to do so. We are located in Oregon. I'm trying to find any information for state legal requirements. Thanks again.
 

SharonCollachi

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Someone with some medical alphabet after their name needs to sign off. A patient can't just come in for a depo shot, the provider has to approve/prescribe it. The provider is responsible for making sure the person providing the service is appropriately trained and appropriately supervised. The medical service isn't complete until the MD/PA/NP/whoever signs off on unlicensed personnel.
 

thomas7331

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The record does have to include an order for the service which is signed by the provider, but there is no universal requirement that a provider must go into every single service documented by the clinical staff and 'sign off'. In a large practice or facility, that would be a huge and largely useless administrative burden. Nursing staff routinely document the services that they perform that are within their scope of practice, and they must sign the record to attest to their work. Payers do routinely audit to ensure that there is a valid order on file for those services, but they do not require that every record of a service by an ancillary staff member by co-signed by the provider.
 
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SharonCollachi

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I don't consider nursing staff and medical assistants to be the same thing. Nursing staff would attest to their own work, but medical assistants, not in my state.
 
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